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The following question refers to Sections 3.3 and 3.4 of the 2021 ESC CV Prevention Guidelines.\n\nThe question is asked by\xa0CardioNerds Academy Intern\xa0student Dr.\xa0Adriana Mares, answered first by\xa0Brigham & Women\u2019s medicine resident & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty\xa0Dr. Allison Bailey.\n\nDr. Bailey is an advanced heart failure and transplant cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology\u2019s Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines.\xa0\n\nThe CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines\xa0represents a collaboration with the\xa0ACC Prevention of CVD Section, the\xa0National Lipid Association, and\xa0Preventive Cardiovascular Nurses Association.\n\nEnjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.\n\n\n\nQuestion #26\n\n\n\nMs. Priya Clampsia is a 58-year-old never-smoker with a history of hypertension. Her BMI is 29 kg/m2. She also mentions having pre-eclampsia during her pregnancy many years ago. She describes a predominately sedentary lifestyle and works as a receptionist. You see her in the clinic to discuss routine preventive care. Her most recent lipid panel results were LDL of 101 mg/dL, HDL of 45 mg/dL, and triglycerides of 190 mg/dL. What additional step will provide valuable information regarding her CVD risk profile?\n\n\nA\nSend additional lab workup including C-reactive protein and lipoprotein (a)\n\n\nB\nMeasure her waist circumference\n\n\nC\nAssess her work stress\n\n\nD\nAsk her about history of preterm birth\n\n\nE\nB, C, and D\n\n\n\n\n\nAnswer #26\n\n\n\nExplanation\nThe correct answer is E \u2013 measuring her waist circumference, assessing her occupational stress, and obtaining history about adverse pregnancy outcomes including preterm birth all add valuable information for CVD risk stratification.\n\nBMI is easily measured and can be used to define categories of body weight. However, body fat stores in visceral tissue carry higher risk than subcutaneous fat and therefore, waist circumference can be a simple way to measure global and abdominal fat. When waist circumference is \u2265102 cm in men and \u226588 cm in women, weight reduction is advised. While these WHO thresholds are widely accepted in Europe, it is important to note that different cut-offs may be appropriate in different ethnic groups.\n\nWork stress is important to ascertain as well because there is preliminary evidence of the detrimental impact of worse stress on ASCVD health, independent of conventional risk factors and their treatment. Work stress is determined by job strain (i.e., the combination of high demands and low control at work) and effort-reward imbalance.\n\nPre-eclampsia is associated with increase in CVD risk by factor of 1.5-2.7 compared with all women. Both preterm (RR 1.6) and still birth (RR 1.5) are also associated with a moderate increase in CVD risk. Taking a thorough pregnancy history is important in determining future cardiovascular risk in women. The ESC guidelines give a Class IIb (LOE B) recommendation that in women with history of premature or stillbirth, periodic screening for hypertension and DM may be considered. Of note, the 2018 ACC/AHA guidelines include preeclampsia and premature menopause (occurring at age <40 years) as risk-enhancing factors for statin therapy but state that the mechanism or cause of preterm birth is often unknown, so it is difficult to include it as a risk-enhancing factor.\n\nChoice A (sending additional lab workup including CRP and LPa) is incorrect. The ESC guidelines do not recommend using routine circulating biomarkers as they do not improve risk prediction and publication bias distorts the evidence (Class III, LOE B). While some biomarkers like lipoprotein (a) are promising, further work is still needed. Conversely, the 2019 ACC/AHA guidelines do include, if measured,